Ulcers are defined as a defect through the muscularis mucosae, that can be of variable depth.We have observed some deep ulcers evolve to an elevated stage, which is opposed to our own ulcer definition and is not described in the literature. MATERIAL and METHODS: We studied prospectively four patients with the following findings in the first endoscopic examination: 1) Male 66 years old with a cardial ulcer that bled massively and was treated with endoscopic injection therapy (Adrenalin 1/10.000)on the 27th of February 1996. 2) Male 56 years old with a gastric, penetrating ulcer in the angle, lesser curvature, June 8th, 1996. 3) Female 74 years old on whom we performed a mucosectomy on the 4th of Frbruary 1997,in an adenoma with areas of carcinoma located at the angle: block resection of 23x16mm. 4) Male 37 years old with severe reflux and Barret's esophagus controlled from 1994. We found a deep esophageal ulcer the 13th of April 1999. After their diagnosis, all the patients were followed up with endoscopy and biopsy, at least in three controls. The ulcerations diameter were from 14 mm(case 1) to 30mm(case2). RESULTS: All the patients showed in their evolution, a very evident elevation, like a sessile polyp in the site of the ulcer. In the gastric location the elevation was pale to reddish, while in the esophagus it was of a clean white color. In the follow up we observed that the protrusion had flattened completely forming a scar in case 2. Case 3 was controlled until the stage of elevated lesion, because of the patient geographic conditions. The slowest regression was the one of the Barret's patient. The elevation persisted for three months and twenty five days, diminishing in size from 16 to 3mm, but later increased to6mm. Case 1 was operated on the 19th of June 1996, because of persistent cardiac ulcer and slight bleeding, performing a subtotal gastrectomy demonstrating a penetrated ulcer with great surrounding inflammatory reaction. COMMENTARY: The protruded ulcer sign is observed rarely but is interesting to be considered as a differential diagnosis and also because it appears in relation to extensive and deep ulcerations. Although our cases are very few, we find that this sign can be observed in gastric or esophageal ulcers, in the evolution of peptic ulcers and in those ulcerations consecutive to the endoscopic ablation when it is extensive.
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